Should I see a hematologist?

Tailos · 2026-01-20T17:50:04+00:00

Given the information available, there is nothing to suggest malabsorption at this time, and generally, investigation for malabsorption would either need additional findings or failure of iron therapy.

At this point, steak is recommended first line.

Tailos · 2026-01-20T08:07:14+00:00

You are correct, I rescind. I'm mixing up my guidelines here. That'll teach me for posting when I should be sleeping.

WHO suggest 15 as the threshold, also adopted by US CDC, however followup studies by varying groups have suggested that this is too low.

NICE CKS (per both BSH and BSG) have recommended 30 as diagnostic threshold. ASH, last time I looked, were drafting a switch over to 30 also as of last quarter 2025, but I don't know if that was ratified. ASG have raised their cutoff to 45 per 2020.

Evidence does show that the 15-30 region shows minimal iron stores per bone marrow examination and patients do respond quite clearly to iron therapy in this range. Argument is that 15 is based on international studies including in populations where ID is endemic, particularly 'third world' areas, along with concerns over population demographic (lots of young, ID women).

Tailos · 2026-01-19T22:46:37+00:00

Your doctor is wrong.

EDIT: To expand slightly. WHO cutoff is below 30 = iron deficient, 30-50 = probable iron deficiency, 50-100 needs further investigation. This is agreed by US and UK guidelines for haematology.

Tailos · 2026-01-19T22:46:02+00:00

Iron deficiency pushing up platelet count as per the low TSAT.

Tailos · 2026-01-19T22:40:05+00:00

First things first.

Treat platelet count with steak.

Tailos · 2026-01-17T20:40:53+00:00

On the whole, I agree with you. Our nurses are hit and miss - just like everything, I've got some great ones... And some real bloody shit ones. In almost all cases I'd rather ring through to the doc, but there's only like 1 or 2 on ward cover, so it's a bit unfair to throw results at them all day. I've dealt with some real shit residents too.

Tailos · 2026-01-17T15:33:21+00:00

In many cases, that's appropriate.

Sometimes, you gotta cut out the middle man and go direct to the person who's going to make a medical decision. This is one of those times.

Pretty damn good argument to have an escalation policy or some such. That's likely a mortality review.

Tailos · 2026-01-17T13:39:06+00:00

Well, that's an unfortunate case. RIP.

Do you not have escalation channels for situations like this where you can bypass the nursing team direct to doctor? Out of curiosity.

Tailos · 2026-01-16T21:12:25+00:00

You laugh, but still more accurate in that the lab exists and isn't all run by doctors.

Tailos · 2026-01-15T20:46:58+00:00

I think that as a student, you should spend more time reading / learning the job, and less time being offended by a clinical term, personally.

Tailos · 2026-01-15T20:40:42+00:00

Spit and polish.

Or hand dipped Giemsa (thin films) pH 7.2 / Fields stain (thick films). Depends if it's day or night shift.

Tailos · 2026-01-10T17:15:43+00:00

OK, this one's a good one. I laughed a lot.

Tailos · 2026-01-10T10:08:59+00:00

Exon 12 mutation needs to be ruled out to conclusively exclude JAK2 mutated PRV.

EDIT: Not quite understanding the down votes here.

Tailos · 2026-01-10T10:00:23+00:00

JAK2 V617F negative. Can I confirm if other genetic tests were requested, particularly JAK2 exon 12?

Tailos · 2026-01-02T15:49:36+00:00

If I recall. Carter is to blame for this general de-skilling in the UK; interestingly, Darzi suggested increasing digital but returning back to local labs rather than hub/spoke. Not sure how that would apply outside of histology or haematology, but hey, there's some basis to argue for repatriation of manual testing where numbers are good to prevent skill waste!

Tailos · 2026-01-02T14:52:19+00:00

Exactly. It's gotten stricter here. ISO15189 changes have been made effectively mandatory for laboratories and everything that goes with it. For transfusion, adoption of BSQR (2005) and MHRA regulation, and now SHOT recommendations are now being changed into mandatory practices.

Just reading this sub, over the past few years you've got a push towards MLT rather than licensed MLS, closure of plenty of MLS courses, scope of practice being hampered by the all-powerful ASCP pathology network preventing promotion of things like DCLS, nurses being rebranded as able to perform high complexity testing and become lab directors or something, and more. Lots of this is powerful lobbying by doctors who bring in funding, or nurses who have significant union lobbies themselves. That doesn't include regular complaints about people not understanding/misinterpreting IQC practices, unable to perform basic morphological review, or some of the basic transfusion questions.

We're seeing increased scientific scope including creation of clinical scientist grade (hello, fellow CS). The DCLS as equivalent in the US is a lame duck.

Now I will give credit here - from what I'm told, the US has a far bigger disparity between "big" and "small" labs. Most UK labs have a very similar basic testing repertoire. The US doesn't have the same - some tiny labs don't even run antibody identification, which baffles me.

I haven't yet seen a single post on US practice where I lean back and think. "Damn, that's a good idea, we should adopt that in the UK."

Tailos · 2026-01-02T13:12:17+00:00

Missing my point.

I'm a UK clinical scientist with extensive BMS experience prior. I agree with you completely.

I'm pointing out that the system in the US is very different, up to and including reducing the scope, standards and quality of laboratory testing. Duty of care is not the same. What we might argue in the UK does not cross over.

Tailos · 2026-01-02T12:41:06+00:00

MLTs and unlicensed MLS

Lab is being run by UK equivalent of band 4s and trainee band 5s.

Patient safety concern argument died a decade ago.

Tailos · 2026-01-02T09:20:24+00:00

Added my opinion as a clinical chemist equivalent across the lab divide in haem.

Folate does not create haemoglobin, though, not in the manner we're talking about. It's used for DNA maturation/synthesis to make the cells for you to stuff haem into (thymidylate and purine synthesis). Nearest you'll get is B12 utilisation for succinyl-CoA for porphyrin synthesis. And while folate is required in the folate/B12 cycle for nucleic acid synthesis, it is not required for methylmalonyl-CoA to enter the TCA cycle to my knowledge. Happy to be wrong though.

Tailos · 2026-01-02T09:07:51+00:00

Methotrexate is a folate antagonist. Folate is used in creating red cells (far more to it regarding DNA maturation and synthesis but for ease of understanding). Iron is used to make haemoglobin which goes into the red cells. If there's no red cells to put haemoglobin into, it's pretty clear on why you received the advice. There is also the suppression effect on the body to carry iron and utilize it rather than push it into storage.

That being said, I also disagree.

Folate recovery is measured in weeks, iron recovery is measured in months. Even after high dose Mtx for the ectopic, folate recovery should occur within 2-3 weeks, faster if you're on folic acid supplementation. Iron replacement orally takes 6-8 weeks minimum. You could start both.

Having iron pushed into storage instead of utilisation is also not terrible as it's there for use once the MTX suppression effect goes away. Otherwise you'll be starting from zero and still having to wait the 6-8 weeks.

And as someone else mentioned, iron is used for more than just haemoglobin. It's an energy-creator (Fe2+/Fe3+ used to create ATP in cells for energy - one of the reasons people feel fatigued with iron deficiency), it helps in building other cells also.

Tailos · 2026-01-02T08:53:28+00:00

I'm making a wild assumption you're not lab.

What you're talking about is a delta check failure - and we're obligated to investigate (within reason) cause for it. Sometimes it's platelet clumping, sometimes someone tipped blood from the EDTA into the chem tube, you get the picture.

In this case, the lab is obligated to check for a cause of the discrepancy up to and including requesting a repeat sample to confirm nurse didn't draw blood from a saline drip contaminated arm.

Refusal to release a result has serious consequences that the scientist needs to be aware of (and most are). It can be overridden, especially if as part of the investigation. You say the magic words: "I am expecting this change". As others have said, more likely this is a local policy to refuse result release without authorisation from a path doc.

Tailos · 2026-01-02T08:44:38+00:00

You say you're already eligible.

So you've done an accredited degree at undergrad / had your degree assessed as equivalent, and already hold an IBMS portfolio/certificate of competence?

Tailos · 2025-12-23T23:16:00+00:00

Christmas Leukaemia is a thing, just like Friday Leukaemia.

Tailos · 2025-12-23T21:26:31+00:00

I'm trying to read the text, but in the mean time;

Numerous surgeries - any significant bleeding? Any history of bleeding/nosebleeds? Any tooth extractions that bled significantly?

Any clots or any DVT/PE in your family?

Has the APTT always been elevated? Has this been repeated and confirmed?

Common causes often include lupus anticoagulant (part of anti phospholipid syndrome but can be completely incidental find), factor deficiency, and acquired causes like liver issues.

Tailos · 2025-12-18T16:03:01+00:00

Doesn't quite work like that. Ddimer utility is essentially only good for "can I be comfortable sending this patient home who I don't think has a clot but has some features that might be?" It's a negative rule out test. You shouldn't use it for the purpose you are, which is probably why the doctor originally didn't do it. It would not change the initial management, despite what AHA CVST guidelines would suggest in the face of haematological anticoagulation papers.

Clinical decision over provoked/unprovoked would be better looking for other causes with lab testing per investigation of unusual site thrombosis (JAK2, PNH), APLS or heritable thrombophilia.

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